1. Page 1 of 3
OBGYN History Report
DEMOGRAPHICAL DATA
Name: …………………………………………….
Age: ………………………………………………
Marital Status: …………………………………….
Gravidity/Parity/Abortions: ………………………
Date/Time of Admission: …………………………
Address: ………….……………………………….
Blood Group: …………………………………….
Occupation: ………………………………………
If pregnant:
LMP: ………….….………....…...…. EDD: ………..….……………...…. GA: ……………………...….
PRESENT COMPLAINT
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HISTORY OF THE PRESENTING COMPLAINT
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PAST M/S HISTORY
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2. Page 2 of 3
HISTORY OF THE CURRENT PREGNANCY
History of antenatal care, complications, labs, investigations, images, supplements, mode of delivery, … etc
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PAST PREGNANCY HISTORY
Preg # Year Sex GA Delivery Mode Weight Complications
MENSTRUAL/GYNAECOLOGICAL HISTORY
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3. Page 3 of 3
DRUG HISTORY
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ALLERGIES
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FAMILY HISTORY
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SOCIAL HISTORY AND LIFESTYLE
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NOTES
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This history form was developed by MohmmadRjab Seder